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Case report

Thursday, May 21th 2015

Management for Giant Retinal Tear in


Rhegmatogenous Retinal Detachment
Case

Andrian Suner*
Consultant
dr. H.A.K Ansyori, SpM(K), Mkes, MARS
dr. Ramzi Amin, SpM(K)

Department of Ophthalmology
Moch Hoesin Hospital
Palembang 2015

INTRODUCTION
Background
Retinal detachment : separation of the
neuroepithelium from the pigment
epithelium occur at potential space.
Potential
space
neuroepitheliumpigment: space between the original
layers of the embryonic optic cup

INTRODUCTION

Retinal detachments are


classified as:
1. Rhegmatogenous (most
common type)
2. Tractional (less common)
3. Exudative

INTRODUCTION
Rhegmatogenous retinal detachment
rhegma(Greek)
caused

= break

by liquefied vitreous passing into the


subretinal space

INTRODUCTION
Epidemiology data:
RD in USA : 12,5 cases/10.000 per year
40-50% Myopic eyes
30% history of Cataract surgery
10-20% associated to ocular trauma (mostly at 25-40 yo)

Principal Management of RD:


Reattachment retina+ close the break + release traction of
vitreoretina
Surgery:
Scleral Buckling
Pars Plana
Vitrectomy
Pneumatic
retinopexy

PURPOSE
To report a case of Rhegmatogenous Retinal
Detachment with Giant Retinal Tear manage
by Scleral Buckle + Pars Plana Vitrectomy +
endolaser + Silicone Oil injection

CASE REPORT
Identification: A boy, 13 yo, rural, came
to
ophthlamology polyclinic at April 15th,
2015.
Chief of Complaint:
Blurred vision at left eye since 2 weeks
ago.

CASE REPORT
History present illness:
2 weeks ago, the patient complain had sudden blurred
vision at left eye with a flash light and floating object
sight at left eye. 2 days later blurry vision became
worse, blur like covered by curtain (+). Patient went to
general practician and referred to private hospital and
last referred to RSMH.
History Past Illness:
Trauma (-)
Spectacle: was used spheric -9 D since 9 years old
Cicatrix on the right eye since patient was born.
Family History
The same disease in family (-)

CASE REPORT
Physical Examination
General Status : Normal

Ophthalmology Status:
RE

LE

VA

NLP

1/300

IOP

P=N+0

5 mmHg

Eye ball
Posititon

Symetric

Eye Ball
Movement

Good to All Gaze

Good to All Gaze

Palpebra

Normal

Normal

CASE REPORT
Conjunctiva

Normal

Normal

Cornea

Cicatrix all over cornea


surface

Clear

Anterior Chamber

Moderate

Moderate

Iris

Posterior synechia (+)

Normal

Pupil

Oval, LR (-) N

Round, Central,LR(+) , 5 mm

Lens

Cant be assessed

Clear

Fundus Reflex

Negative

Positive

Papil Cant be assessed

Macula
Retina

Round, blurred margin, Normal Red


Colour, C/D: Cant be assessed
A/V:2/3
Foveal reflex(-)
4 quadrants detachment (+), giant
retinal tear (+) temporal region.

CASE REPORT
LEFT EYE FUNDUS PHOTOGRAPH

CASE REPORT
RETINAL DRAWING
RE

LEFT EYE USG

RIGHT EYE USG

CASE REPORT
Diagnosis :
Rhegmatogenous Retinal Detachment LE + Cornea
Leukoma RE + Retinal Detachment LE
Management:
Informed Consent
Hospitalized
Laboratorium Examination + Chest X-Ray
Pro consult Anesthesiology Department
Pro Scleral Buckle + Pars Plana Vitrectomy + Endolaser +
Silicone Oil LE with General Anesthesia

Prognosis :
Quo ad Vitam
: Bonam
Quo ad Functionam : Dubia ad bonam

CASE REPORT
Surgical Report: (21-4-2015)
1.
Patient in supine position with GA
2.
Aseptic & antiseptic performed, surgical field was narrowed
3.
3600 conjunctival peritomy & extraocular muscle isolated
4.
Silicone band inserted under rectus muscle, Sleeve installed at
nasal inferior & band sutured to sclera at 4 with mersilene 5.0
5.
Sclerotomy site marked at 3 mm from limbal and at 8 oclock filled
infusion cannula, 10 oclock-vitrector & 2 oclock-endoilluminator
6.
Detached retina and tear was identified, proceed to performing
vitrectomy until optimal clearance

CASE REPORT
7. Heavy fluid injected to stabilize retina and to do the endodrainage
8. fluid-air exchange performed, endolaser applied around tear and
3600 peripheral retina
9. Silicone Oil injected to vitreal cavity
10. Infusion cannula,endoilluminator & vitrector were removed from
cavity & sclera sutured with 8.0 vycril
11. Dexamethason-gentamycin injected subconjunctival and eye
was closed with sterile patch

Post opertive therapy


Cefixime 2 x 100 mg
Paracetamol 3 x 250 mg
Metil prednisolon 3x 4 mg
Tobramycine + dexametason ED 6 x 1
gtt OD

CASE REPORT (FOLLOW UP)


Right Eye

1st day post op

VA

4/60 PH(-)

IOP

13,1 mmHg

8th day post op


6/60 ph (-)
15,6 mmHg

FR

(+)

(+)

Papil

Round, Firm margin, Normal Red Colour,


C/D:0,3 A/V:2/3

Round, Firm margin, Normal Red


Colour, C/D:0,3 A/V:2/3

Macula

Foveal reflex (+)

Foveal reflex(+)

Retina

Tigroid appearance, Lattice degeneration


(+) , scar laser (+), subretinal hemorrhagic
(+)

Tigroid appearance, Lattice


degeneration (+), scar laser (+),
subretinal hemorrhagic (+)

CASE REPORT
1st day post op

9th day post op

Diagnosi Post Buckle Sklera + pars


s
plana vitrectomy+ Endolaser +
Silicon oil LE+ corneal leucoma
RE + Retinal detachment RE

Post Buckle Sklera + pars


plana vitrectomy+ Endolaser
+ Silicon oil LE+ corneal
leucoma RE + Retinal
detachment RE

Therapy

Tobramycine + dexametason
ED 6 x 1 gtt OD

Cefixime 2 x 100 mg
Paracetamol 3 x 250 mg
Metil prednisolon 3x 4 mg
Tobramycine + dexametason
ED 6 x 1 gtt OD

LITERATURE REVIEW

RETIN
A

It extends almost as far anteriorly


as the ciliary body
Ending point The ora serrata
The outer surface of the sensory
retina is apposed to the retinal
pigment epithelium and thus
related to Bruch's membrane, the
choroid, and the sclera.

RETINA

Thickness 0.1 mm at the ora


serrata and 0.56 mm at the
posterior pole
The macula lutea is defined
anatomically as the 3 mm diameter
area containing the yellow luteal
pigment xanthophyll

FOVEA

The retinal avascular zone of


fluorescein angiography.
1.5 mm

FOVEOL
A

A depression that creates a


particular reflection when viewed
ophthalmoscopically.
In the center of the macula 4
mm lateral to the optic disk
0.25 mm

FOVEOL
A

In the middle of
The thinnest part of area of the
retina 0.25 mm
Only cone photoreceptors.
Providing optimal visual acuity.

LITERATURE REVIEW

Retinal detachment: separation of the


sensory retina from the pigment epithelium
which occur at potential space.

LITERATURE REVIEW

Normally, sensoryneural attach to RPE maintained


by balance hydrostatic. RPE preserve the potential
space free from fluid by osmotic gradient and
active-pump mechanism.

3 major factor of RD:


full-thickness retinal defect (break)
Traction of retina
Subretinal fluid

LITERATURE REVIEW
Potential space in RD filled with
subretinal fluid. Fluid came from
syneretic vitreous through retinal break
and separate the sensory retina from
RPE

LITERATURE REVIEW
Risk factor:
Myopic eye
Trauma
Lattice degeneration
History of surgery
Family history
Lattice degeneration is a predisposing factor of RRD. 8 % of
population have lattice and 40% case of RD associated with
lattice

SYMPTOMS
Metamorphopsia
Photopsia
Shadow or curtain over a portion of
visual field
Blur in vision

LITERATURE REVIEW
Management of RRD:
find and close the break
Reattachment retina
Post operative outcome depend on:
Macular involvement
duration of separation until surgical management
apply

LITERATURE REVIEW
Surgical Technique
1. Scleral Buckling
Scleral indentation

Silicone
band

Tyre

Chorioretinal adhesion

Cryo

Laser

Drainage

Retinopexy
SF6

C3F8

Performed : single break & peripheral


good visualization
only in 1 quadrant 90% good result

LITERATURE REVIEW
SCLERAL BUCKLING COMPLICATION

LITERATURE REVIEW
2. Vitrectomy
Rationally, vitrectomy is a procedure to
overcome
traction
and
avoid
complication of scleral buckling.
RRD associated vitreous mobility (liquefaction & PVD)

VITRECTOMY
clean up hyaloid cortex of vitreous avoid vitreoretinal traction_
Scleral
Buckle

Relaxation vitreal
traction

LITERATURE REVIEW
VITRECTOMY PROCEDURE

INDICATION
Disease:
Diabetic Retinopathy
PVR
Macular involvement
Trauma
Malignancy case

Condition:
Giant tears
Vitreous hemorrhage
Multiple break
Equatorial tear

LITERATURE REVIEW
Vitrectomy Complication

Intra operative

Post operative

Iatrogenic break

Increase IOP
(silicone,
buckling)

Iatrogenic to lens

Cataract form
Hyphema (heavy
fluid to AC)
CME
PVR

Giant retinal tears circumferential


retinal breaks of 90 degrees or more

The general principles of management:


Unfold the posterior flap of the tear
Flatten it against the eye wall
Seal the tear with a fi rm adhesion.

DISCUSSION
Anamnesis
Sudden blur vision
No reddish eye
Photopsia
Floaters
Curtain-like vision

Seeing flash light


(photopsia) and Flying
matter( floaters) are 50%
of RRD early symptoms.

DISCUSSION
Fundus Examination:

Retinal detachment (undulation


bulae)

Foveal involvement

Giant retinal tear

Lattice degeneration

DISCUSSION

History of wearing spectacles (+) -9D high


miopia lattice degeneration

Lattice degeneration:
Abnormal condition of retina caused by thinning
of inner limitting membrane with athropic process
of neurosensory, which is lead retinal break
formation migration of vitreous fluid subretinal
the sensory retinaRPE separation

Management for this patient is Sclera


buckle + Pars Plana Vitrectomy +
Endolaser + Injection Silicone Oil
Intravitreal
Giant retinal tear

46

Reason :

Retinal detachment shallow

Good identification of retinal tear

Post operative outcome:


Complication not found
Retinal flat (+)
Visual acuity improvement at follow up

Prognosis :
Quo ad vitam
: bonam
Quo ad fungsional : dubia ad bonam

Follow Up : better visual acquity,


attached retina, no complication

CONCLUSION
Its have been reported a case of Rhegmatogen
retinal detachment with giant retinal tear managed
by Sclera buckle + Pars Plana Vitrectomy +
Endolaser + Injection silicone oil intravitreal.
RRD caused by lattice degeneration history of
high miopia.
Prognosis dubia ad bonam for this patient better
visual acquity, attached retina, no complication

THANK YOU

RALAT
Prognosis : dubia ad bonam
Setelah tindakan operasi didapatkan
retina yang attach dan perbaikan tajam
penglihatan pada follow up, serta tidak
didapatkan komplikasi tindakan bedah.

LASER TISSUE EFFECT

Photocoagulation effects.

Thermal effects, those most commonly


encountered with retinal photocoagulation
visible or infrared light is absorbed by tissue
pigment absorption of laser energy results in a
10 to 20 C temperature rise --- protein
denaturation is seen clinically as tissue whitening

LASER TISSUE EFFECT

Thermal effects.

SYMPTOMS
floaters - bits of debris in field of
vision that look like spots, hairs or
strings

LITERATURE REVIEW
Vitrectomy + Scleral Buckle

Degenerasi lattice merupakan


kelainan dari permukaan
vitreoretinal, dapat ditemukan 610% dari populasi umum dan
bilateral pada 1/3 sampai
jumlahkasusdegenerasi lattice.
Degenerasi lattice sering muncul
pada pasien dengan miopia, tapi
tidak hanya terbatas pada pasien

VITRECTOMY CUTTER BAUSH AND


LOMB

Retinal breaks

a - Large U-tear with


subclinical RD
- treat

c - Operculated tear bridged


by blood vessel
- treat

b - Large symptomatic U-tear


- treat

d - Asymptomatic operculated
tear
- do not treat

Retinal breaks not requiring treatment

e - Asymptomatic dialysis
surrounded by pigment

g - Small asymptomatic holes


near ora serrata

f - Breaks in both layers of


retinoschisis

h - Small inner layer holes in


retinoschisis

Typical lattice degeneration

Present in about 8% of general population


Present in about 40% of eyes with RD
Vitreous

Retina

Spindle-shaped islands of retinal thinning


Network of white lines within islands
Variable associated RPE changes
Small round holes within lesions are common

Overlying vitreous liquefaction


Exaggerated attachments
around margin of lesion

Complications of lattice degeneration

No complications - in most cases


RD associated with atropic holes, particularly in young myopes
RD associated with tractional tears in eyes with acute PVD

Indications for prophylaxis

RD in fellow eye
Extensive lattice in high myopia

CLASSIFICATION OF PVR

The term "proliferative vitreoretinopathy" was coined in


1983 by the Retina Society Terminology Committee.
In 1989, the classification was amended by the Silicone
Study Group before being most recently modified in 1991 to
its current classification.
Currently, PVR is divided into grades A, B, and C.
Grade A is limited to the presence of vitreous cells or haze.
Grade B is defined by the presence of rolled or irregular
edges of a tear or inner retinal surface wrinkling, denoting
subclinical contraction.
Grade C is recognized by the presence of preretinal or
subretinal membranes. Grade C is further delineated as
being anterior to the equator (grade Ca) or posterior to the
equator (grade Cp) and by the number of clock hours
involved (1 to 12).

Proliferative vitreoretinopathy
Grade A (minimal)

Vitreous haze and


tobacco dust

Grade B (moderate)

Retinal wrinkling and


stiffness
Rolled edges of tears

Grade C (severe)

Rigid retinal folds


Vitreous condensations
and strands

PRINCIPLES OF RETINAL DETACHMENT SURGERY

1. Scleral buckling

Configuration of buckles
Preliminary steps
Localization of breaks
Insertion of local explant
Encircling procedure
Drainage of subretinal fluid

2. Pneumatic retinopexy
3. Vitrectomy
Giant tears
Proliferative vitreoretinopathy (PVR)
Diabetic tractional RD

Vitrectomy for Retinal Detachment

Release of circumferential
traction

Release of anteroposterior traction

Endophotocoagulation

Vitrectomy for PVR

Dissection of star folds and peeling of membranes


Injection of expanding gas or silicone oil

Intraocular gases
Sulfur hexafluoride (SF6)
perfluoropropane (C3F8) are the gases
most frequently used.
Success also has been reported with
sterile room air.

Preliminary steps

Peritomy

Insertion of bridle suture

Insertion of squint hook under


rectus muscle

Inspection of sclera for thinning


or anomalous vortex veins

Encircling procedure

Strap fed under four recti

Ends secured with Watzke sleeve

Strap slid posteriorly and secured


in each quadrant

Strap tightened to produce required


amount of internal indentation